The U.S. maternal health care system is at a crossroads. A 2024 March of Dimes Report Card assigned the country a D+ rating for maternal and infant health, for the third consecutive year, underscoring persistent failures despite the resources and technology available. While the Biden administration took steps toward reform — including extending postpartum Medicaid coverage from 60 days to 12 months, expanding community-based care, and improving rural maternal health services — recent policy shifts under President Donald Trump are putting those advancements at serious risk. If left unchallenged, these changes could dismantle crucial support for maternal health care and further widen the already devastating gaps in care.
Sarah Alley, a certified professional midwife, understands firsthand how gaps in maternal care affect families, particularly in rural areas. “There are just so many times where I’m at a birth, at least an hour, maybe an hour and a half from the closest hospital, that will take a woman in labor,” she said. Long distances to medical facilities have long been a challenge in maternity care deserts, and the national response has been inadequate. More than 5.6 million women now live in areas with limited or no obstetric services. Since 2021, more than 50 hospitals in Texas alone have either closed or drastically reduced their labor and delivery services. The expansion of these maternity care deserts directly correlates with worsening maternal and infant mortality rates.
But just as some states had begun implementing Biden-era Medicaid expansions to improve access to care, the Trump administration has placed those efforts in jeopardy. The administration has endorsed a House Republican budget plan that proposes deep cuts to Medicaid funding, including the rollback of the 12-month postpartum Medicaid extension. This plan seeks to reduce federal Medicaid spending by $880 billion over the next decade, potentially eliminating health care coverage for millions of low-income individuals. Without these protections, new mothers, especially in states that had only recently expanded postpartum care, could once again find themselves without critical medical support in the first year after giving birth.
Adding to these concerns, Trump has already revoked executive orders from the Biden era that strengthened Medicaid and the Affordable Care Act (ACA). His administration is also considering implementing work requirements for Medicaid eligibility, a move that could result in thousands of women losing access to essential maternal health services due to administrative hurdles. These policy shifts threaten to undo progress in reducing maternal mortality, leaving millions of expectant and new mothers without necessary support.
Maternity Care Deserts Are Putting Mothers and Infants at Risk
For Black women, who already face disproportionately high maternal mortality rates, the impact of these rollbacks is even more severe. According to March of Dimes, Black women in the U.S. are nearly three times more likely to die from pregnancy-related complications than white women. Beyond maternal mortality, the risks extend to infants as well. The organization’s latest data shows that more than 370,000 babies were born preterm in 2023, accounting for 10.4% of all births — the third consecutive year the nation has received a D+ for preterm birth. Infant mortality also rose by 3% in 2023, the largest single-year increase in more than two decades. Black infants remain at significantly higher risk, with a preterm birth rate of 14.7% — approximately 1.4 times higher than the rate for all other women. These deaths are preventable, yet they persist due to systemic failures in prenatal care, limited access to community-based support, and worsening environmental conditions that disproportionately impact marginalized communities.
Findings from the latest March of Dimes Report Card highlight that environmental stressors — including extreme heat, air pollution, and exposure to unsafe drinking water — continue to drive higher rates of pregnancy complications, particularly among low-income families and communities of color. Pregnant individuals exposed to these factors are at greater risk for hypertensive disorders, preterm labor, and low birth weight. Without consistent access to prenatal care — already difficult due to Medicaid restrictions — these complications often go undiagnosed or untreated, further increasing risks for both mother and child.
Transportation barriers also play a significant role in maternal health outcomes, particularly in rural maternity care deserts where hospitals are hours away. For individuals without reliable transportation or access to Medicaid-covered ride services, attending routine prenatal checkups can be difficult, if not impossible. Studies show that missing prenatal visits is directly correlated with higher rates of preterm birth and pregnancy-related complications, yet Medicaid cuts threaten to make transportation assistance even less available for those who need it most.
Further compounding these challenges, the Trump administration has not committed to extending Medicaid-covered telehealth services, which are set to expire on March 31, 2025, unless Congress acts. Telehealth has been a lifeline for expectant parents in rural areas, providing remote access to prenatal care, maternal-fetal specialists, and postpartum support that otherwise requires hours of travel. Without an extension, millions of Medicaid recipients — including pregnant individuals in maternity care deserts — will lose virtual access to essential maternal health services, making it even harder for them to receive timely care.
Alley, who has worked across multiple states, has seen how these disparities manifest in real time. While much of the focus is on access to hospitals and medical providers, the barriers go deeper. The ability to maintain a healthy pregnancy often depends on financial stability, particularly when it comes to affording prenatal vitamins, nutritious food, and preventative screenings. “The quality of diet is a major concern,” she noted. “Healthy food is expensive food. And if people can’t afford healthy food, they can’t afford the things that make a pregnancy healthier.” For many families, Medicaid cuts won’t just mean fewer doctor visits — it will mean harder choices about whether to spend limited resources on essential nutrients or other pressing needs.
Expanding Medicaid for Midwifery and Doula Care Can Save Lives
Despite these troubling trends, the expansion of midwifery and doula services presents a tangible solution to improve birth outcomes — especially in underserved communities. Midwives provide personalized, continuous care that emphasizes education and self-advocacy, helping parents make informed decisions about their pregnancies. “I help women know what their options are in birth,” Alley said, reinforcing the role midwives play in fostering empowerment and informed choice.
Recent research reinforces just how critical these services are. A 2023 study published in the American Journal of Obstetrics and Gynecology found that patients who received doula care were more likely to attend postpartum health visits and had higher rates of successful vaginal births after cesarean (VBAC), key indicators of improved maternal outcomes. The Office of the Assistant Secretary for Planning and Evaluation (ASPE) also reported in 2022 that Medicaid recipients who had access to doula support saw lower rates of preterm birth and cesarean deliveries — both of which are major contributors to maternal and infant mortality.
Doulas, who provide nonmedical emotional and physical support during pregnancy and childbirth, are also proving to be critical in closing the gap in maternal care. Research has consistently shown that doulas help lower maternal stress, which is a well-documented risk factor for preterm labor. Their presence has been linked to lower rates of preterm birth and a reduction in labor complications. In states that have integrated doula services into Medicaid coverage, early data suggest improved outcomes and increased patient confidence in the birthing process.
But access to these services depends on continued policy support. Despite the clear evidence supporting these programs, recent federal budget proposals threaten their future. Trump’s proposed Medicaid cuts — totaling $880 billion over the next decade — place these vital services at risk. The rollback of Medicaid protections not only threatens existing maternal health care programs but could also hinder the ability of states to fund midwifery and doula services. Expanding Medicaid coverage to fully include these services would be a major step toward reversing the maternal mortality crisis. States that have already broadened Medicaid eligibility for community-based maternal care have seen clear improvements in birth outcomes. Without continued expansion, millions of women — particularly those in rural and low-income communities — will remain at risk.
The urgency of this crisis cannot be overstated. The D+ rating from the March of Dimes Report Card is not just an indictment of the current system — it is a warning that without immediate action, the situation will worsen. If Medicaid cuts move forward as proposed, preterm birth rates will rise, racial disparities will deepen, and maternal deaths will continue to increase. The U.S. has already seen a decline in maternal and infant health outcomes, and eliminating Medicaid coverage for midwifery and doula care is projected to further exacerbate these disparities.
Midwifery and doula services improve birth outcomes, lower cesarean rates, reduce preterm births, and increase postpartum support. Yet, access to these services remains out of reach for many. Medicaid-covered telehealth and transportation programs help close the gap for expectant parents in maternity care deserts, but these programs, too, are at risk. Without immediate action, more families will lose access to care, deepening the maternal health crisis.
What You Can Do
- Contact Your Representatives: Urge lawmakers to oppose Medicaid cuts and protect funding for maternal health programs.
- Advocate for Community-Based Care: Support local midwifery and doula programs and demand their inclusion in state Medicaid plans.
- Stay Informed and Vote: Follow policy changes and hold elected officials accountable for decisions that impact maternal and infant health.
- Engage in Grassroots Advocacy: Join maternal health organizations and participate in initiatives that push for systemic reform.
The U.S. maternal health care crisis is not an inevitability — it is a problem that can and must be addressed. The nation is at a crossroads, and the choices made now will determine whether the next generation of mothers and infants faces a system in decline or one that has been transformed to prioritize health, equity, and survival.
